Psilocybin-Assisted Psychotherapy for Psychiatric Illness ...2019/... · Psilocybin Can Occasion...

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Psilocybin-Assisted Psychotherapy for Psychiatric Illness: Research Update

Josh Woolley, MD, PhDDirector of the Bonding and Attunement in Neuropsychiatric Disorders LabDepartment of Psychiatry, University of California, San Francisco

Faculty Disclosure• Dr. Woolley: Employee—University of California, San Francisco

(UCSF), San Francisco VA Medical Center (SFVA); Site Principal Investigator (UCSF)—psilocybin Phase 2 trial (sponsored by Usona Institute), MDMA Phase 3 trial (sponsored by MAPS); Research Support (UCSF)—Hefter Research Institute, UsonaInstitute.

Disclosure• The faculty have been informed of their responsibility to disclose

to the audience if they will be discussing off-label or investigational use(s) of drugs, products, and/or devices (any use not approved by the US Food and Drug Administration).– Psilocybin does not have an FDA-approved indication for any psychiatric

disorder.

• Applicable CME staff have no relationships to disclose relating to the subject matter of this activity.

• This activity has been independently reviewed for balance.

Learning Objectives

• Assess the psychotherapeutic benefits and risks of psilocybin-assisted psychotherapy

• Compare and contrast psilocybin-assisted psychotherapy with current models of mental health treatment involving psychiatric medications +/- psychotherapy

• Discuss the current status of the field of psilocybin-assisted psychotherapy, including its current legal and regulatory status

Psilocybin• Active ingredient in over 180 species of hallucinogenic mushroom

• Used in religious and healing practices in various cultures for centuries

• Predominant 5-HT2A receptor agonist

• 5 to 6 hours duration

• Potent effects on mood, cognition, and behavior – “Like dreaming while awake”

Allen JW, et al. Ethnomycology and distribution of the psilocybian mushrooms. In: Metzner R (Ed). Sacred mushroom of visions: Teonanacatl: A sourcebook on the psilocybin mushroom. Rochester, VT: Inner Traditions/Bear; 2005. Stamets P. Psilocybin mushrooms of the world: An identification guide. Berkeley, CA: Ten Speed; 1996. Wasson RG. The wondrous mushroom: Mycolatry in Mesoamerica. New York, NY: McGraw-Hill; 1980.

Lewis CR, et al. Neuroimage. 2017;159:70-78.

Psilocybin

1959: Isolated from P. Mexicana

1950–1960s: Produced by Sandoz

1971: CSA Schedule I substance

1990s: Human study at UNM (not published)

2004: FDA-approved clinical trial for anxiety in late-stage cancer

Rapidly dephosphorylated to psilocinMixed serotonin agonistPrimary effects through 5-HT2A receptor

PharmacokineticsDose 14–30.1 mg/70 kg PO Metabolism

– UDP-glucuronosyltransferases– < 2% renally excreted unchanged

Timeline Pharmacodynamics

CSA = Controlled Substance Act; UNM = University of New Mexico. Brown RT, et al. Clin Pharmacokinet. 2017;56(12):1543-1554. Passie T, et al. Addict Biol. 2002;7(4):357-364.

PsilocybinClinical Experience and Safety

1950–1960sParticipants: > 350 in > 13 studies

1960–1980sPatients: > 1500 in various clinical contexts

2000–2019Participants: > 275 (patients + healthy volunteers) Serious Adverse Events: Zero

US Food and Drug Administration Investigational New Drug (IND) 113080.

Psilocybin (not Psilocybe mushrooms) is used in modern clinical trials

Psilocybin Psilocin

Wikipedia.org.

PsilocinSerotoninPsilocin is an agonist at Serotonin 1A, 2A, 2C Receptors

Wikipedia.org.

Psilocybin Can Occasion Mystical-Type Experiences Having Substantial and Sustained Personal Meaning

and Spiritual Significance• 2 to 3, 8-hour sessions at 2-month intervals

– Psilocybin (30 mg/70 kg) or methylphenidate (40 mg/70 kg) administered at beginning of session

• Follow-up surveys administered 2 months after each session

• Double-blind, crossover design

• N=24 (average age = 46 years, 58% male, healthy)Griffiths RR, et al. Psychopharmacology. 2006;187(3):268-283; 284-292.

Psilocybin Raises Blood Pressure

Griffiths RR, et al. Psychopharmacology. 2006;187(3):268-283; 284-292.

Monitor Ratings during Sessions

Outcome Measures Description MPH Psilocybin P value

Persisting Effects Questionnaire (volunteer ratings)

Positive attitudes about life and/or self 22.8 (4.5) 55.0 (5.0) <.001

Negative attitudes about life and/or self 0.3 (0.1) 0.5 (0.3) NS

Positive mood changes 16.0 (3.5) 39.2 (5.3) <.001

Negative mood changes 0.6 (0.5) 1.5 (0.7) NS

Altruistic/positive social effects 17.3 (4.4) 46.6 (5.5) <.001

Antisocial/negative social effects 0.3 (0.2) 0.7 (0.5) NS

Positive behavior changes 29.2 (6.5) 60.0 (4.8) <.001

Negative behavior changes 1.7 (1.2) 0 (0) NS

Did the experience change your sense of

well-being or life satisfaction?+0.79 (0.18) +2.04 (0.17) <.001

Community Observer Ratings Positive change score −0.03 (0.68) 2.42 (0.70) <.01

Psilocybin Experiences are Very Personally Meaningful

Psilocybin Binds to 5-HT2A Receptors across the Cortex

Madsen MK, et al. Neuropsychopharmacology. 2019;44(7):1328-1334.

Psychedelic Effects of Psilocybin Correlate with Plasma Psilocin Levels

And 5-HT2A Receptor Occupancy

Psilocybin Decreases Global Brain Perfusion

But Increases Relative Brain Perfusion

Summary

gCBF = global cerebral blood flow; IFG = inferior frontal gyrus; rCBF = regional cerebral blood flow.Lewis CR, et al. Neuroimage. 2017;159:70-78.

Hariri AR, et al. Neuroimage. 2002;17(1):317-323. Kraehenmann R, et al. Biol Psychiatry. 2015;78(8):572-581.

Psilocybin Decreases Amygdala Reactivity

And Increases Positive Affect

PANAS = Positive and Negative Affect Schedule; STAI = State-Trait Anxiety Inventory.Kraehenmann R, et al. Biol Psychiatry. 2015;78(8):572-581.

And the Two are Correlated

Kraehenmann R, et al. Biol Psychiatry. 2015;78(8):572-581.

Roseman L, et al. Front Hum Neurosci. 2014;8:204.

Psychedelic-Assisted Psychotherapy

(No Rx) Preparation sessions(~ 6–8 hours)

(Rx) Treatment session(~ 8 hours)

(No Rx) Integration sessions(~ 4–8 hours)

Important Elements of Psychedelic-Assisted Psychotherapy

• Preparation – create sense of safety and holding environment

• Nondirective approach to therapy

• Beginner’s Mind – setting aside expectations

• Trust in an Inner Healing Capacity

• Music

• Integration – essential and ongoing

21st Century Human Research with PsilocybinClinical Indications

Existential Distress and Depression

Obsessive-Compulsive Disorder

Tobacco Use Disorder

Alcohol Use Disorder

Cocaine Use Disorder

Clinical and Non-clinical Studies

Total participants ~ 600

> 2000 doses administered

Zero Significant Adverse Events

0 1 2 3

Demoralization in HIV

Cluster Headaches

Cocaine

Depression

Alcohol

Tobacco

Anx/Dep in Cancer

Phase I Phase II

Psilocybin and FDA Drug Development

OCD = obsessive-compulsive disorder.

Psilocybin Produces Substantial and Sustained Decreases in Depression and Anxiety in

Patients with Life-Threatening Cancer5-week crossover of psilocybin: Low dose (1 mg/70 kg or 3 mg/70 kg) vs High dose (22 mg/70 kg or 30 mg/70 kg)

N=51 (49% women) with potentially life-threatening cancer diagnosis and DSM diagnosis:

Adjustment disorder, chronic Dysthymia (mild depression)GADMDD

GAD = generalized anxiety disorder; MDD = major depressive disorder.Griffiths RR, et al. J Psychopharmacol. 2016;30(12):1181-1197.

Safety Outcomes

Significant Adverse EventsZero

Adverse EventsHypertension

Nausea / vomitingAnxiety

ParanoiaHeadaches

Griffiths RR, et al. J Psychopharmacol. 2016;30(12):1181-1197.

HAMD = Hamilton Rating Scale for Depression.Griffiths RR, et al. J Psychopharmacol. 2016;30(12):1181-1197.

HADS = Hospital Anxiety and Depression Scale; HAM-A = Hamilton Anxiety Rating Scale; LAP-R = Life Attitude Profile-Revised; POMS = Profile of Mood States.Griffiths RR, et al. J Psychopharmacol. 2016;30(12):1181-1197.

Meaningfulness and Spiritual Significance

Griffiths RR, et al. J Psychopharmacol. 2016;30(12):1181-1197.

Rapid and Sustained Symptom Reduction following Psilocybin Treatment for Anxiety and Depression in

Patients with Life-Threatening Cancer• 2 sessions of psychotherapy over 9 months

– Psilocybin (21 mg/70 kg) or niacin (250 mg) at the beginning of the session

• Follow-up assessment performed 26 weeks after second session

• Double-blind, randomized, crossover design

• N=14 (average age = 56 years, 38% male, cancer comorbid with depression or anxiety)

Ross S, et al. J Psychopharmacol. 2016;30(12):1165-1180.

BDI = Beck Depression Inventory.Ross S, et al. J Psychopharmacol. 2016;30(12):1165-1180.

Belser AB, et al. Patient experiences of psilocybin-assisted psychotherapy: an interpretative phenomenological analysis. Journal of Humanistic Psychology. 2017;57(4):354-388.

Psilocybin Trial Participants

“It led to a re-awakening of what it felt like when my first daughter, Tanya, died. And the feelings just came flooding up. I was completely into the sense of despair and loss that I had when she died. And I howled. And I felt comforted that my guides won’t come and comfort they won’t stop me, they’ll let me go into it. And I did. And that was almost 30 years of, not denial, but putting it down, suppressing of what that felt. And that was very liberating.”

Treatment-Resistant Depression

N=12.Carhart-Harris RL, et al. Lancet Psychiatry. 2016;3(7):619-627.

QIDS = Quick Inventory of Depressive Symptoms.Carhart-Harris RL, et al. Lancet Psychiatry. 2016;3(7):619-627.

Carhart-Harris RL, et al. Lancet Psychiatry. 2016;3(7):619-627.

Smoking Cessation

• 2 to 3 psilocybin doses (20–30 mg/70 kg) given on weeks 5, 7, and 13 of 15-week treatment program

• Follow-ups at 10 weeks, 6 months, and 12 months– Urine and breath samples collected at

week 10

• N=15 (average age = 51 years, 67% men, nicotine dependence with previous attempt[s] to quit)

Johnson MW, et al. Am J Drug Alcohol Abuse. 2017;43(1):55-60.

Alcohol Dependence

• Psilocybin (14 mg/70 kg) administered during 2 sessions 4 weeks apart

• Single-group design

• Data collected over 36 weeks

• N=10 (average age = 40 years, 60% men, DSM-IV alcohol dependence)

Bogenschutz MP, et al. J Psychopharmacol. 2015;29(3):289-299.

Status Authors/Institution Outcomes Study Design N Results

Completed, published 2014

Johnson, et al.John Hopkins

SafetyTobacco smoking

abstinence

Open label pilot study2–3 drug treatment sessions 15

80% demonstrated biological abstinence at

6-month follow-up

Ongoing John Hopkins Tobacco smoking abstinence

RCT; 1 drug treatment session with psilocybin or nicotine replacement therapy patch

95 N/A

Completed, published 2015

Bogenschutz, et al.UNM

SafetyAlcohol cravings

Heavy drinking days

Open-label pilot study2 drug treatment sessions 10

Increase in abstinence from alcohol P<.05 and reduced

cravings P<.001 at 36 weeksNo serious adverse events

Ongoing NYU and UNM SafetyHeavy drinking days

Randomized double-blind trial1–2 drug treatment sessions

with psilocybin or diphenhydramine

180 N/A

OngoingUniversity of Alabama at Birmingham

Cocaine abstinenceRandomized double-blind trial1 drug treatment session with psilocybin or diphenhydramine

40 N/A

Coming soon…University of Wisconsin at

Madison

Methamphetamine use reduction N/A N/A N/A

Summary of Clinical Studies on Psilocybin for Substance Use Disorders

Psilocybin at UCSF: Long-Term AIDS Survivors

Brian Anderson, MD

Long-Term AIDS Survivors

Diagnosed early in the AIDS Epidemic

Formerly “terminally ill”

2015: > 50% HIV+ in the United States are > 50 years old

Long-Term AIDS SurvivorsChronic Existential Distress

Traumatic Loss / Complicated Grief

Isolation and Loneliness

Depression

Risky Substance Use and Sex

Anecdotally: High Suicide Rate

Photo: San Francisco Chronicle.

Study DesignDesign

Psilocybin-assisted group psychotherapyPhase 1, single-arm, open-labelN=18 (3 groups of 6)

Primary Outcomes1. Safety2. Feasibility3. Primary: Demoralization (Baseline – Endpoint)4. Secondary: PTSD symptoms (Baseline – Endpoint)

PTSD = posttraumatic stress disorder.Anderson B, et al. T137. Psilocybin-Assisted Group Therapy for Demoralization in Long-Term AIDS Survivors. Biol Psychiatry. 2019;85(10 Suppl):S182.

Study DesignInclusion LTAS

Gay-identified men > 50 years oldModerate-to-severe Demoralization (DS-II)

ExclusionAntidepressants, mood stabilizers, antipsychoticsPsychiatric instabilityUnstable cardiovascular or other major medical diseaseAbnormal ECG and basic laboratory studies

DS-II = Demoralization Scale-II; ECG = electrocardiogram; LTAS = long-term AIDS survivors.

Study DesignBrief Supportive-Expressive Group Therapy

90-minute sessions; 2 group therapists

Process group; “here and now” oriented

Mutual support, expression of emotion, active coping skills

Classen CC, et al. Psychooncology. 2008;17(5):438-447. Classen C, et al. Arch Gen Psychiatry. 2001;58(5):494-501. Spiegel D, et al. Arch Gen Psychiatry. 1981;38(5):527-533.

Mean (SD) Range

Age (years) 59.2 (4.4) 49.5–66

Year of HIV/AIDS/GRID Diagnosis 1988 (4.8) 1981–1996

Montreal Cognitive Assessment (MoCA) 27.9 (1.4) 24–30

Lifetime: People close to you who have died 25.8 (26.9) 2–100

Lifetime: Psychedelic use 29.8 (52.3) 0–200

Years since last used psychedelics 15.8 (19) 1 mo–46 yrs

Demographics

Screening, Enrollment, and Retention:

Nov 2017 – Jan 2019

Participant Diagnoses#1 GAD, PCL-5 = 35#2 MDD, GAD, Panic, PCL-5 = 51#3 MDD#4 MDD#5 MDD, GAD, Panic, BPD#6 GAD, Panic, BPD#7 MDD, GAD, BPD, PCL-5 = 49#8 GAD

#10–18 None

Current SCID-5 Diagnoses at Enrollment Evaluated for: MDD, GAD, Panic Disorder, OCD, Cluster B Personality Disorders

BPD = borderline personality disorder; PTSD Checklist for DSM-5 = PCL-5; SCID-5 = Structured Clinical Interview for DSM-5.

SAE Primary Term # of Participants (%), n=18

Relatedness to Psilocybin

Highest Severity Observed

During TrialRenal Cell CarcinomaRecurrence, Metastatic 1 (6%) Unrelated Severe

Pneumothorax 1 (6%) Unrelated SevereDuring Follow-upStimulant-induced Psychosis 1 (6%) Unrelated Potentially life-

threatening

Suicide Attempt 1 (6%) Unrelated Potentially life-threatening

SuicidalityC-SSRS: No clinically significant change from Baseline to Endpoint

Related to Psilocybin Unrelated to PsilocybinDuring Trial During Follow-up During Trial During Follow-up

0 0 2 2

Serious Adverse Events

AE Primary Term # of Participants (%), n=18

Highest Severity Observed Expectedness

PsychiatricAnxiety 6 (33%) Severe ExpectedParanoia / ideas of reference 4 (22%) MildThought disorder 1 (6%) ModerateNon-psychiatricHypertension 17 (94%) SevereTachycardia 2 (11%) MildNausea 6 (33%) MildMotor agitation / marked restlessness 4 (22%) ModerateUnsteady gait / ataxia 4 (22%) ModerateHeadache 3 (17%) ModeratePhysical discomfort / pain 1 (6%) ModerateUrinary incontinence 1 (6%) Moderate Expected

Medication Visit Adverse Events

AE Primary Term # of Participants (%), n=18

Highest Severity Observed Expectedness

Headache 8 (44%) Mild ExpectedFatigue 2 (11%) Moderate ExpectedInsomnia 2 (11%) Mild Expected

Anxiety Exacerbation– Methamphetamine relapse 1 (6%) Severe

ModerateExpected

UnexpectedPost-traumatic Stress– Flashback– Tinnitus – Nausea– Panic– Insomnia

1 (6%) Moderate Unexpected– Unexpected – Expected– Expected– Expected– Expected

Nausea 1 (6%) Mild Expected

Post-Medication Visit Adverse EventsPsilocybin-Related

Baseline Preparation Week 1-2 Endpoint(Week 3-4)

3 MonthFollow Up

PTSD Checklist 5(Mean, N=18)

PTSD Likely

PTSD Unlikely

Psilocybin*P=.004, Hedge’s g=.74

4 Group Therapy Sessions

4–6 Group Therapy Sessions

Challenging Experiences26-items

7 FactorsFear, grief, physical

distress, insanity, isolation, death, and paranoia

Day after medication session

Not at all

Extremely

= Beneficial = Harmful

9 10 11 12

Discussion

Psilocybin-assisted group therapy is feasible

Psilocybin therapy in demoralized LTAS can be safe

Large effect sizes on pre-post demoralization, PTSD symptoms

Limitations

Open-label, no control arm

Poor generalizability (LTAS)

Non-standard clinical indication

Selection bias, expectancy effects

Summary• Psilocybin is safe to administer in controlled medical settings

• Psilocybin-assisted therapy shows promising effects for demoralization, depression, and substance use disorders although studies are small and not well controlled

• Binds to 5-HT2A receptors which appear to mediate psychological effects

• Causes widespread neural changes including altering resting state networks and amygdala processing– However, clinical mechanisms of action are unclear

Psilocybin-Assisted Psychotherapy for Psychiatric Illness ...2019/... · Psilocybin Can Occasion...

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